2025 Annual Conference

Kenneth Cohen MD, FACP, Executive Director of Translational Research, Optum Health; and Omid Ameli, MD, DrPH, Senior Principal Research Scientist, Optum Center for Research and Innovation

The 2021 ACC/ASA guideline recommends long-term rhythm monitoring to detect intermittent atrial fibrillation (AF) after cryptogenic stroke. As the guideline is based on AF detection, not reduction in recurrent stroke, there is a need for studying additional clinical outcomes associated with this strategy. This poster presentation compares the effectiveness, safety, and costs of implantable loop recorders (ILR) with continuous external monitors (CEM) and Holter monitors in a real-world setting of patients with stroke.

Upon completion of this activity, participants should be able to:

• Compare impact of implantable loop recorders, in a large real world sample, with long term external monitors and Holter, across a broad range of clinical, safety, and utilization.
• Compare cost of care between ILR and external cardiac monitoring.
• Gain insights about the impact of ILR on a comprehensive range of health outcomes.

Eric Cain, MD, MBA; Kapil Dhingra, MD, MBA, FACEP; and Aparna Gulati, MD, The Permanente Medical Group

This poster presentation addresses gaps in knowledge and competence regarding tailored diabetes care for LatinX patients. It covers culturally sensitive interventions, patient engagement strategies, and outcomes of the LatinX Diabetes Pathway, aiming to enhance healthcare professionals’ ability to manage diabetes effectively within this underserved community.

Upon completion of this activity, participants should be able to:

• Describe the principal aim and structure of the LatinX Diabetes Pathway and its tailored health education interventions designed to improve diabetes management outcomes for LatinX patients.
• Identify socio-economic barriers faced by LatinX patients in managing diabetes, such as language and cultural differences, and understand how the program addresses these issues to promote equitable healthcare.
• Analyze the outcomes of the LatinX Diabetes Pathway, including improvements in glucose meter utilization, medication adherence, participation in education classes, and blood pressure control, and discuss the potential for scaling this program across other KP markets.

Suelyn C. Boucree, MD, MBA, FACP, Network Director of Quality, Hackensack Meridian Health and Assistant Clinical Professor, Hackensack Meridian School of Medicine; and Jojy Cheriyan MD, PhD, MPH, MPhil, Physician Enterprise Division Corp Integration and Assistant Professor, Department of Neurology, Hackensack Meridian School of Medicine, Hackensack Meridien Health

In March 2020, Hackensack Meridian Health launched a network-wide colorectal screening campaign aimed at addressing their historically low screening rates. Given colorectal cancer's status as the second leading cause of cancer-related deaths, they undertook a comprehensive improvement initiative. This poster presentation describes the six components of Hackensack Meridian Health’s phased approach: 1) Awareness and education; 2) Enhancing access and testing availability; 3) Optimized technology for enhanced patient engagement and seamless lab data capture; 4) Standardizing screening guidelines to enhance clinical consistency and patient care; 5) Enhancing continuity of care through automated follow-up and AI integration; and 6) Addressing disparities in CRC screening.

Upon completion of this activity, participants should be able to:

• Identify cancer at an early stage when treatment is most effective, significantly reducing mortality rates. 
• Employ diverse screening approaches to cater to patient preferences and enhance participation rates.
• Optimize their local EHR to support shared decision-making, facilitating informed choices, and introduce risk-tailored screening protocols that account for individual factors to maximize screening efficacy. 
• Refine their workflow to integrate screening for social determinants of health and prioritize addressing geographic, socioeconomic, and cultural obstacles to ensure equitable access to screening, particularly for underserved and high-risk populations.
• Establish systematic follow-up for positive screening outcomes and coordinate care from initial screening through diagnosis and treatment, enhancing patient outcomes and optimizing the care continuum.

Elizabeth Ruvalcaba, MSPH, Senior Research Project Lead; Alicia Rooney, MPH, MSW, Population Health Research Analyst; Meghana Tallam, MPH, Population Health Research Analyst, AMGA; Christian Ragland, MPA, Assistant VP, Diversity Equity and Inclusion; and Laura Tanner, RN, MSN, Director of Quality, Prevea

Addressing health equity requires innovative and multi-level interventions to address disparities in care. This poster presentation describes diverse strategies implemented by 3 health systems to promote equity for COVID-19 management, showcasing real-world efforts and outcomes – with the aim to inspire broader adoption and continuous improvement in advancing equitable health outcomes for all.

Upon completion of this activity, participants should be able to:

• Name 1-3 provider or health system level interventions that can be deployed by health systems to address health equity for COVID-19 treatment.
• Name 1-3 patient or community level interventions that can be deployed by health systems to address health equity for COVID-19 treatment.
• Understand barriers to health equity in COVID-19 management.

Alicia Rooney, MPH, MSW, Population Health Research Analyst; Elizabeth Ciemins, PhD, MPH, MA, Senior VP, Research & Analytics, AMGA; Pamela Schoemer, MD, Quality Director, University of Pittsburgh Medical Center; and Monika Mahal, MD, PeaceHealth

Despite HPV vaccine efficacy, gaps exist in coverage. Several AMGA member organizations have begun initiating the vaccine at ages 9 and 10 with a goal of increasing completion by age 13. This poster presentation describes best practices learned from surveys and interviews of 5 member organizations who have successfully implemented earlier initiation. 

Upon completion of this activity, participants should be able to:

• Name three strategies used by the organizations studied to improve HPV vaccination rates for 9-10-year-olds. 
• Describe two benefits of initiation of HPV vaccination at ages 9-10. 

Kimberlydawn Wisdom, MD, MS, FACEP, Senior Vice President, Community Health & Equity, Chief Wellness and Diversity Officer; David Fuller, Jr., MHSA, Program Manager, Community Health Integrated Operations, Community Health, Equity, Wellness and Diversity; Stephanie Robinson, MHA, Manager, Physician Partnership Network; and Emily Morrow, MBA, MLS (ASCP)cm, Product Manager, Populace, Henry Ford Health

This poster presentation describes a multidisciplinary, data-driven approach to enhance patient satisfaction, trust, and transparency in privacy and data sharing. Strategies include leveraging data-driven insights, scaling Empathic Inquiry training, and standardizing patient-facing messaging.

Upon completion of this activity, participants should be able to:

• Identify the best practices in conducting SDoH screenings by leveraging technology, evidenced-based training, and communication strategies.
• Expand their utilization of a Community Information Exchange (CIE) and electronic closed-loop referrals to enhance regulatory performance.
• Understand the importance of the individual conducting the SDoH screen, as well as the setting in which they are doing it, which are important for establishing patient trust through the screening process.

Morgan Drexler, MPH, CPH, PMP, Program Manager, AMGA Foundation; Stephen Shields, MPH, Lead Population Health Research Analyst, AMGA; and Gina Aquino, DNP, RN, CHSP, Henry Ford Medical Group

This poster presentation covers AMGA Foundation’s Rise to Immunize Campaign’s progress to date - working collectively to improve adult immunization care. One high performing health system shares their best practices to help peers improve their adult immunization rates, including closing immunization care gaps, benchmarking performance, and implementing care processes such as provider and staff education, clinical support, patient education, IT/documentation, and financial management.

Upon completion of this activity, participants should be able to:

• Identify the impact and progress of the campaign.
• Recognize the value of resources and educational opportunities to improve immunization care.
• Understand best practices to improve adult immunization rates.